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The Doctors Were Real, the Patients Undercover

EDE, the Netherlands — It had all the markings of a television detective show. Posing as patients, three undercover observers got themselves admitted as patients to a locked psychiatric ward to investigate conditions on the inside.

Each undercover patient had rehearsed an extensive back story, and the supposed family members who visited them were professional actors. A remote team monitored the project via hidden cameras and microphones from a command center in a nearby hotel.

The project, which took place this spring in De Gelderse Roos, a psychiatric complex about 40 miles from Amsterdam, was not a sting operation. The staff was told there would be mystery shoppers, of a sort, in the facility over a couple of months.

“We didn’t go in there like cowboys,” said Menko Soeters, a partner at Clearfields, a consulting firm that developed the project with De Gelderse Roos. “But we did use an unorthodox instrument for psychiatric care.”

Surrounded by manicured greenery, the closed-off ward of the complex, known as De Riethorst, recalls a suburban dental clinic, and its sunny gymnasium and carpeted hallways do little to suggest that it houses up to a dozen acute psychiatric patients, many of whom are there involuntarily.

And that is why the undercover participants were all experienced psychiatric nurses. “You couldn’t have done it otherwise,” said Edo De Vries, the director of De Gelderse Roos, which released the results of the project last summer.

It and Clearfields are working on a project for 2010, most likely to involve five to eight psychiatric hospitals in the Netherlands.

Mr. De Vries said the impetus for the project came in part from a pair of patient deaths last year in psychiatric facilities in Amsterdam — one involving a suicide, the other a man who choked on food while locked in an isolation cell. Several managers and staff members were fired as a result, and others were suspended.

“Of course, incidents can happen anywhere,” Mr. De Vries said. “But what if there is something structurally wrong that we don’t know about? We have to be more transparent, and I think this method is a good tool for that.”

Because this initiative was the first of its kind, the goal in Ede was to see whether such a project was even practical.

The untested nature of the project meant the organizers prepared as meticulously as possible.

The undercover patients developed their fictive biographies in months of meetings with an acting coach and a psychotherapist. “Ronald,” for example, was a middle-aged man with a history of aggression problems, and after a supposed suicide attempt he was taken to De Riethorst by an actor playing his brother. To make their stories believable, the patients memorized details about where their children went to school or which supermarket they shopped at, and the psychotherapist advised them on how to present their given mental illness convincingly.

To ensure their safety, the fake patients checked in via text message every three hours, and they carried letters identifying them as plants. A code word (“fireplace”) was in place if they had to communicate genuine distress to visitors. The visitors wore hidden cameras and microphones; the undercover patients did not.

The warning to the staff about the undercover patients made the project more amenable to Martien Opdam, a psychiatric nurse at De Riethorst who worked while the plants were there. Though he and his colleagues did wonder who the plants might be, he said: “You can’t keep doing that for two months. You go back to your routine.”

He said the experience was helpful. “It taught me not to go too much on autopilot,” he said.

Among the findings of the project were that patients frequently found it difficult to get information on their treatment and medications and that the sound of a staff member’s key chain jangling could be jarring to an already anxious patient.

Malingering one’s way into a psychiatric ward to report on conditions within has been a journalistic staple since as far back as 1887, when Nellie Bly got herself admitted to the insane asylum on Blackwells Island (now Roosevelt Island) in New York City. Similar endeavors have been the subject of many books and television documentaries over the years.

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The best-known scientific example remains the experiments by David Rosenhan, a psychologist. He and seven other “pseudopatients” got themselves admitted to a dozen hospitals by pretending to hear voices, and the study, published in Science magazine in 1973 as “On Being Sane in Insane Places,” is still widely seen as a critique of psychiatric diagnosis.

In the July issue of the journal Psychiatric Services, Arthur Lazarus, a psychiatrist with decades of experience in the health insurance and pharmaceutical industries, wrote a commentary supporting the use of mystery shoppers in mental health care, though not in in-patient settings and only if the staff is informed.

Dr. Lazarus suggested in an interview that perhaps doctors themselves could play the role of undercover patients. “I think there is an opportunity to get beyond the mere fact that the carpet is dirty or the staff is rude,” he said.

Likewise, Dr. James Sabin, a Harvard Medical School professor as well as a medical ethicist for Harvard Pilgrim Health Care, sees possibilities. “It’s technically much more challenging in a psychiatric hospital,” Dr. Sabin said, “but it’s certainly doable.” He said it could help doctors “try to fathom what is it like for the people we’re dealing with.”

Opponents of the idea think enough ways already exist. Melissa Miller, a licensed clinical social worker based in Sarasota, Fla., said mystery shopping in mental-health settings was “an intrusive redundancy.”

“The field is really already well covered with ways to have checks and balances,” Ms. Miller said, including surveys and exit interviews with staff members and patients.

She said that having snooping eyes in her practice would violate the implicit trust between doctor and patient. “I could imagine having to have my client sign a statement saying, ‘I am not a mystery shopper,’ ” she said. “Otherwise how can I be free to give my professional self to the therapy?”

Last year, the ethics council of the American Medical Association considered issuing guidelines for the use of “secret shopper patients,” but the measure has not advanced.

Many medical professionals object to the use of real doctors and resources by fake patients. For the project in Ede, the organizers had made provisions to relocate the undercover patients if there were a sudden shortage of beds.

The potential in mystery shopping for reality television has also been explored.

Richard Bentall, a professor of clinical psychology at the University of Bangor in Wales, took part in a 2008 BBC program called “How Mad Are You?” The program challenged medical experts to distinguish between “normal” volunteers and those with a history of mental illness. Despite the gimmicky nature of the show, Dr. Bentall said he was “cautiously in favor” of projects like the recent Dutch example.

“Having covert observation is going to provide you with information you probably wouldn’t get in any other way,” he said.

But Dr. Bentall also sees some irony in using proxy mental patients to illuminate the experiences of real ones. “Their stories are neglected,” he said, “and their understanding of how they got to be in the hospital is not considered important.”

There are some signs of change in that respect. The National Alliance on Mental Illness, for example, recently began using mental health care consumers to rate the Web sites and telephone switchboards of various facilities.

As Dr. Bentall put it: “It’s common sense, really. Involve the customers in the decision-making, and you’re going to get a better product.”

A version of this article appears in print on December 1, 2009, on Page D5 of the National edition with the headline: The Doctors Were Real, The Patients Undercover. Order Reprints|Today's Paper|Subscribe